We investigated significant predictors of poor in-hospital outcomes for patients admitted with viral pneumonia during the COVID-19 outbreak in Tehran, Iran. Between February 22 and March 22, 2020, patients who were admitted to three university hospitals during the COVID-19 outbreak in Tehran, Iran were included. Demographic, clinical, laboratory, and chest CT scan findings were gathered. Two radiologists evaluated the distribution and CT features of the lesions and also scored the extent of lung involvement as the sum of three zones in each lung. Of 228 included patients, 45 patients (19.7%) required ICU admission and 34 patients (14.9%) died. According to regression analysis, older age (OR = 1.06; P < 0.001), blood oxygen saturation (SpO2) < 88% (OR = 2.88; P = 0.03), and higher chest CT total score (OR = 1.10; P = 0.03) were significant predictors for inhospital death. The same three variables were also recognized as significant predictors for invasive respiratory support: SpO2 < 88% (OR = 3.97, P = 0.002), older age (OR = 1.05, P < 0.001), and higher CT total score (OR = 1.13, P = 0.008). Potential predictors of invasive respiratory support and in-hospital death in patients with viral pneumonia were older age, SpO2 < 88%, and higher chest CT score.

Since coronavirus disease 2019 (COVID-19) is associated with a hypercoagulable state, especially in critical patients, anticoagulation is used for thromboprophylaxis. Hemorrhagic complications, even uncommon ones such as retroperitoneal hemorrhage, can occur following anticoagulant administration. We present 5 patients with COVID-19 whose clinical course was complicated by spontaneous retroperitoneal hemorrhage. The patients were initially presented with respiratory manifestations of the infection. There was no history or evidence suggestive for traumatic injury. After hospitalization, the patients received supplemental oxygen, antibiotics, enoxaparin or heparin, interferon beta-1b (in three patients), and anticoagulation with subcutaneous injection of enoxaparin (three patients) or heparin (two patients). During the course of hospitalization, the patients showed sudden-onset abdominal pain (three cases), hypotension (three cases), and an acute drop in hemoglobin level. CT scan of the abdomen and pelvis revealed retroperitoneal hemorrhage. For one patient, owing to unstable vital signs and an expanding hematoma, surgical intervention was performed. Others were managed conservatively with discontinuation of anticoagulants, intravenous (IV) fluid resuscitation, and packed red blood cells transfusion. Three patients died due to worsening of the infection and respiratory failure. Retroperitoneal hemorrhage could be a potential complication in COVID-19 patients receiving anticoagulation. Careful monitoring of the vital signs and blood tests like hemoglobin level of such patients is essential.

Key Clinical MessageAccidental/suicidal ingestion of metal phosphides (e.g., zinc phosphide found in rodenticides) should be suspected in patients with sudden‐onset abdominal pain, refractory hypotension, and metabolic acidosis. CT angiography may show radiopaque substance in the stomach and early enhancement of the inferior vena cava and contrast in right side of the heart.